Psychological impact of trauma on developing children and youth

All too often, children and adolescents are exposed to traumatic events that lead to physical injury in many cases, psychological perturbation in most cases, and enduring psychological reactions, notably posttraumatic stress disorder, in a minority of individuals. This sequence of events can affect later development, learning, emotions, and behavior. In the process of caring for the physical injury, it is important for the primary care practitioner (PCP) to correctly interpret these presentations and anticipate the need for specific assessments, immediate intervention, referral, and follow-up. This report provides the foundation for such actions on the part of the PCP.

Learning disorders in children and adolescents

Findings indicate that students with severe learning disabilities can profit from instruction geared toward abstract higher-order comprehension when it is designed according to their particular instructional requirements. Early intervention improves outcomes for most children with disorders of learning, attention, and cognition. Impairments in the physical, language, sensory, or mental domains are usually harder to diagnose before a child's entry into school system, but they are easier to treat if caught early. Children with above-average intellectual abilities often have the ability to compensate or master appropriate coping mechanisms that greatly minimize their overall negative outcomes. Parental attitudes and commitment, availability of resources, and the presence of an associated neurologic deficit or medical disorder can also significantly impact outcomes.

The adolescent sexual offender

Although the research on adolescent sexual offenders is limited, what we do know is sobering. Adolescents less than 18 years of age account for 20% of arrests for all sexual offenses (excluding prostitution). These youth reside in urban and rural areas and may be brought into the physician's office by their parents for help with addressing this maladaptive behavior. Family physicians may also get involved during a sexual abuse investigation, and may be called on to facilitate initial evaluation and coordination of services. Physicians who are aware of adolescent sexual offending can increase their ability to detect adolescents who have aberrant or deviant sexual behavior patterns allowing for early referral and intervention.

Neural correlates of dispositional mindfulness during affect labeling

OBJECTIVE

Mindfulness is a process whereby one is aware and receptive to present moment experiences. Although mindfulness-enhancing interventions reduce pathological mental and physical health symptoms across a wide variety of conditions and diseases, the mechanisms underlying these effects remain unknown. Converging evidence from the mindfulness and neuroscience literature suggests that labeling affect may be one mechanism for these effects.

METHODS

Participants (n = 27) indicated trait levels of mindfulness and then completed an affect labeling task while undergoing functional magnetic resonance imaging. The labeling task consisted of matching facial expressions to appropriate affect words (affect labeling) or to gender-appropriate names (gender labeling control task).

RESULTS

After controlling for multiple individual difference measures, dispositional mindfulness was associated with greater widespread prefrontal cortical activation, and reduced bilateral amygdala activity during affect labeling, compared with the gender labeling control task. Further, strong negative associations were found between areas of prefrontal cortex and right amygdala responses in participants high in mindfulness but not in participants low in mindfulness.

CONCLUSIONS

The present findings with a dispositional measure of mindfulness suggest one potential neurocognitive mechanism for understanding how mindfulness meditation interventions reduce negative affect and improve health outcomes, showing that mindfulness is associated with enhanced prefrontal cortical regulation of affect through labeling of negative affective stimuli.

Changing illness perceptions in patients with poorly controlled type 2 diabetes, a randomised controlled trial of a family-based intervention: protocol and pilot study

BACKGROUND

This paper presents the pilot study and protocol for a randomised controlled trial to test the effectiveness of a psychological, family-based intervention to improve outcomes in those with poorly controlled type 2 diabetes. The intervention has been designed to change the illness perceptions of patients with poorly controlled type 2 diabetes, and their family members. It is a complex psychological intervention, developed from the Self-Regulatory Model of Illness Behaviour. The important influence the family context can have in psychological interventions and diabetes management is also recognised, by the inclusion of patients' family members.

METHODS/DESIGN

We aim to recruit 122 patients with persistently poorly controlled diabetes. Patients are deemed to have persistent poor control when at least two out of their last three HbA1c readings are 8.0% or over. Patients nominate a family member to participate with them, and this patient/family member dyad is randomly allocated to either the intervention or control group. Participants in the control group receive their usual care. Participants in the intervention group participate, with their family members, in three intervention sessions. Sessions one and two are delivered in the participant's home by a health psychologist. Session one takes place approximately one week after session two, with the third session, a follow-up telephone call, one week later. The intervention is based upon clarifying the illness perceptions of both the patient and the family member, examining how they influence self-management behaviours, improving the degree of similarity of patient and family member perceptions in a positive direction and developing personalized action plans to improve diabetes management.

DISCUSSION

This study is the first of its kind to incorporate the evidence from illness perceptions research into developing and applying an intervention for people with poorly controlled diabetes and their families. This study also acknowledges the important role of family members in effective diabetes care.

TRIAL REGISTRATION

ISRCTN62219234.

Religiosity/spirituality and behavioral medicine: investigations concerning the integration of spirit with body

This article introduces the special section on Religiosity/Spirituality and Behavioral Medicine. After brief comments on the increase in interest in this topic and related definition concerns, each of the five articles that comprise the special section is presented.

Constructing safety: System designs, system effects, and the play of heterogeneous interests in a behavioral health care setting

OBJECTIVE

This paper considers the utility of actor-network theory as a basis for uncovering the mutual interdependencies between system design and system impact in an evolving project, and for exploring the implications that these interdependencies hold for the production of safety in behavioral health care.

METHODS

Drawing on a field study of a systems project in a human-services firm, the paper applies key concepts from actor-network theory in the analysis of a design crisis that emerged during the course of the project.

RESULTS

Actor-network theory provides a compelling framework in this situation for identifying the diverse interests involved, revealing their complex interactions, and illuminating the importance of the emerging system as an organizational actor in its own right.

CONCLUSION

Actor-network theory shows promise for use in other analyses concerned with the role of information technology in the construction of safety in health care settings.

Suicide in Children and Adolescents

The tragedy of suicide in children and adolescents is considered a national and global phenomenon. There are approximately 900,000 suicides in the world each year, including as many as 200,000 adolescents and young adults. Suicide rates vary from country to country depending on local factors, including reporting methods. Causes of suicide include depression; abuse; loss of friends (including boyfriend or girlfriend); academic failure; social isolation; and substance abuse. The link between use of antidepressants and suicidal ideation is discussed, and concepts of management are also considered.

Sexuality in the Child, Teen, and Young Adult: Concepts for the Clinician

This article discusses basic concepts of sexuality in children, adolescents, and young adults based on development stages. Sexual behavior of adolescents is a common phenomenon, leading to sexually transmitted diseases (STDs) and unwanted pregnancy. Clinicians should provide anticipatory guidance to help with healthy sexuality development while reducing negative aspects of human sexuality. Comprehensive sexuality education should be provided, with emphasis on avoiding unwanted sexual advances (including Internet dangers), bullying, pregnancy, and STDs. Clinicians can teach sexually active patients to use effective contraception and condoms for STD protection. Ensuring full immunization with the hepatitis B vaccine and the human papillomavirus vaccine also is important.

Prevention of type 2 diabetes in a primary health care setting. Interim results from the Greater Green Triangle (GGT) Diabetes Prevention Project

Although clinical trials have shown that lifestyle modifications reduce the risk of type 2 diabetes, translating lessons from trials to primary care remains a challenge. The aim of the study was to evaluate efficacy and feasibility of primary care-based diabetes prevention model with modest resource requirements in rural Australia. Three hundred and eleven subjects with at least a moderate risk of type 2 diabetes participated in a combined dietary and physical activity intervention. Clinical measurements and fasting blood samples were taken at the baseline and after intervention. After 3 months intervention, total (change -3.5%, p<0.001) and LDL cholesterol (-4.8%, p<0.001) plasma levels as well as body mass index (-2.5%, p<0.001), weight (-2.5%, p<0.001), and waist (-1.6%, p<0.001) and hip (-2.7%, p<0.001) circumferences reduced significantly. A borderline reduction was found in triglyceride levels (-4.8%, p=0.058) while no changes were observed in HDL cholesterol (+0.6%, p=0.525), glucose (+0.06%, p=0.386), or systolic (-0.98%, p=0.095) or diastolic (-1.06%, p=0.134) blood pressure levels. In conclusion, a lifestyle intervention improved health outcomes - especially obesity and blood lipids - in a population at high risk of developing type 2 diabetes. Our results suggest that the present model is effective and feasible to carry out in primary care settings.

ADHD in Children, Adolescents, and Adults

Attention-deficit-hyperactivity disorder (ADHD) is a commonly occurring, heritable neurobehavioral disorder distributed worldwide that does not typically resolve after childhood. The significant impact of ADHD on an individual's family, relationships, educational performance, and performance at work is now well established. Medical treatment of ADHD is effective, not only alleviating symptoms but also improving overall functioning. It is imperative that primary care physicians be well versed in this disorder and its clinical features across the age groups. The primary care physician should be able to screen, diagnose, educate, and initiate medication management in patients with uncomplicated ADHD.

Intellectual Disability (Mental Retardation) in Children and Adolescents

Mental retardation or MR (current term, intellectual disability [ID]) is a label used to describe a constellation of symptoms that includes severe deficits or limitations in an individual's developmental skills in several areas or domains of function: cognitive, language, motor, auditory, psychosocial, moral judgment, and specific integrative adaptive (ie, activities of daily living). This article reviews concepts of ID in children and adolescents useful for the primary care clinician who cares for these individuals. The majority of youth with ID can live independent or semi-independent lives as adults if they have received the appropriate personalized support over a sustained period of their lives, especially during the formative years.

Psychologic Impact of Deafness on the Child and Adolescent

The purpose of this article is to provide a brief overview of the psychologic impact (stimuli and events that influence cognitive, social, and emotional development) of deafness on children and adolescents. In addition, methods for connecting with families to provide information, support, and resources to enhance deaf children's development are described.

Pediatric Insomnia: A Behavioral Approach

This article discusses the two common causes of insomnia in children, behavioral insomnia of childhood and delayed sleep phase syndrome. Both of these conditions are primarily treated with behavioral interventions that can be initiated and managed by the primary care provider. A review of these behavioral interventions is provided.

Measuring clinically meaningful change following mental health treatment

Assessment of clinically meaningful change is useful for treatment planning, monitoring progress, and evaluating treatment response. Outcome studies often assess statistically significant change, which may not be clinically meaningful. Study objectives are to: (1) evaluate responsiveness of the BASIS-24 using three methods for determining clinically meaningful change: reliable change index (RCI), effect size (ES), and standard error of measurement (SEM); and (2) determine which method provides an estimate of clinically meaningful change most concordant with other change measures. BASIS-24 assessments were obtained at two time points for 1,397 inpatients and 850 outpatients. The proportion showing clinically meaningful change using each method was compared to the proportion showing change in global mental health, retrospectively reported change, and clinician-assessed change. BASIS-24 demonstrated responsiveness at both aggregate and individual levels. Regarding clinically meaningful improvement and decline, SEM was most concordant with all three outcome measures; regarding no change, RCI was most concordant with all three measures.

The sustainability of systems of care for children's mental health: lessons learned

The federal Comprehensive Community Mental Health Services for Children and Their Families Program was initiated in 1992 to provide grants to states, communities, territories, and Indian tribes to develop systems of care to serve children and adolescents with or at risk for emotional disorders and their families. As part of the national evaluation of this program, a study was undertaken to assess the ability of funded sites to sustain their systems of care beyond the federal grant period. The study involved a web survey and telephone interviews with local and state respondents to examine the extent to which key components of systems of care were maintained during the period in which federal funds were phasing out and during the post grant period. Study results demonstrate positive and negative changes that occurred in the communities which are included in the sample, with respect to maintaining the availability of each service included in the broad service array, the implementation of system of care principles, the system of care infrastructure, and the achievement of system of care goals. In addition, results identify factors that contribute to or impede the ability to sustain systems of care, and the effectiveness of various strategies for sustainability. Study findings offer guidance not only to federally funded system of care communities but also to non-funded communities engaged in system of care development to enhance their ability to sustain systems of care for this population over time. Findings will also assist federal, state, and local policymakers, technical assistance providers, family members, advocates, and other key stakeholders to more effectively support the development of viable, sustainable systems of care.

Efficacy of lifestyle behavior change programs in diabetes

Evidence that a comprehensive lifestyle behavior change program targeting eating and physical activity, and ultimately weight loss, can alter the course of diabetes progression is growing. This report summarizes data from major clinical trials primarily, describes key features of behavior change programs, and comments on existing challenges regarding the adequacy, sustainability, and feasibility of behavior change programs for weight loss and diabetes prevention.

Smoking during pregnancy: where next for stage-based interventions?

Pregnancy is a 'window of opportunity' for encouraging positive behaviour change, such as quitting smoking. Associations have been shown between smoking stage of change and other health behaviour during pregnancy. For example, women in the precontemplative stage have poorer assessment of risks associated with smoking, feel less personally responsible for their unborn child's health and in turn are less likely to adopt health-promoting behaviour. Stage of change models are a popular tool within the health services, but the results of stage-based smoking cessation interventions are mixed. Identifying the crucial components of effective interventions is an important imperative for research in this area. This article reviews the literature to ascertain these components and makes recommendations for designing effective interventions.

Efficacy and effectiveness trials: examples from smoking cessation and bullying prevention

If health psychology is to maximize impacts on health, there will need to be a shift from relying primarily on efficacy trials to increasing reliance on effectiveness trials. Efficacy trials use homogeneous, highly motivated samples with minimal complications from a single setting receiving intensive treatments delivered under highly controlled conditions. Two effectiveness trials on bullying prevention illustrate the use of a heterogeneous population from multiple sites receiving a low intensity tailored treatment delivered under highly variable conditions. In spite of considerable noise the effectiveness trials produced robust results (odds ratios of about four) that bode well for population impacts under real-world dissemination.

Cultural competency and recovery within diverse populations

Recovery for diverse populations with mental health problems includes communities of color, those with limited English proficiency and individuals who are lesbian, gay, bisexual or transgender (LGBT). The process of healing and recovery must take into consideration the critical role of culture and language and look at the individual within the context of an environment that is influenced by racism, sexism, colonization, homophobia, and poverty as well as the stigma and shame associated with having a mental illness. Recovery must assess the impact of isolation brought about by cultural and language barriers and work towards reducing the negative influence it has on the emotional and physical well-being of the person. It is imperative that recovery occur at multiple levels and involves the person in recovery, the service provider, the larger community and the system that establishes policies that often work against those who do not fit the mold of what mainstream society considers being "the norm." Recovery must respect the cultural and language backgrounds of the individual.

Recovery: a common vision for the fields of mental health and addictions

The vision of recovery is reshaping the fields of mental health and addiction services. This paper reviews how this broad vision is shaping common goals, principles, values and strategies across the two fields. We further examine how a common vision of recovery can positively impact the treatment of co-occurring disorders and speculate on how this vision can bridge the seeming differences between these two fields and reshape a mutual understanding of the essentials of recovery from severe mental illness and addiction.

Free will in context: a contemporary philosophical perspective

Philosophical work on free will is inevitably framed by the problem of free will and determinism. This paper offers an overview of the current state of the philosophical art. Early sections focus on quantum indeterminism, an outline of the most influential logical argument for incompatibilism between free will and determinism, and telling problems that face incompatibilism. A major portion of the paper focuses on the compatiblist alternative, favored by many working philosophers. The conditional account of free will offered by classical compatibilism can be shown to be inadequate. A number of compatibilist options remain open, however, and seem promising for future research. These include "hierarchical" or "mesh" accounts of free will, normative perspectives and an approach to free will in terms of an emphasis on context. Final sections draw out the implications of contemporary compatibilism for the brain and behavioral sciences and for the law.